Malignant soft tissue tumours

dikuliahkan oleh :
dr. Su Djie To Rante, M.Biomed, SpOT
FK Undana

slide from : Dr. Ian Dickinson

Princess Alexandra & Wesley Hospitals
Brisbane, Australia
Soft Tissue Tumours
• Malignant
• Malignant Fibrous Histiocytoma 30%
• Pleomorphic storiform (Now “undifferentiated pleomorphic”)
• Myxofibrosarcoma 10%
• Liposarcoma 20%
• Lipoma like
• Myxoid
• Small cell
• Leiomyosarcoma 15%
• Synovial sarcoma 15%

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Soft Tissue Tumours – the rest
• Epitheloid sarcoma
• Dermatofibrosarcoma protruberans
• Neurofibrosarcoma
• Fibrosarcoma
• Clear cell sarcoma
• Alveolar soft parts sarcoma
• Extraskeletal myxoid
chondrosarcoma
• Acral myxoinflammatory
fibrosarcoma
• Pleomorphic tumour of soft parts
• Rhabdomyosarcoma
• Giant cell tumour of soft parts
• Osteosarcoma
• Solitary fibrous tumour
• DESMOID TUMOUR
(Aggressive Fibromatosis)
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• More common than malignant bone tumours
• Can come in any size
• Can arise in any mesenchymal site
• Commonest in the largest muscle areas:
• ie thigh, buttock. Also retroperitoneal.
• Prognosis related to:
• Size: 0-5cm; 5-10cm; >10cm
• Grade
• Specific tumour types

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Metastasis
• Blood borne to the lung:
• Chest x-ray surveillance (+/- CT)
• Some can metastasise to lymph nodes:
• Epitheloid
• Synovial
• Dermatofibrosarcoma
• Clear cell sarcoma
• Any late disease sarcoma
• Some metastasize to other sites:
• Myxoid tumours especially myxofibrosarcoma

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Investigations
• Local:
• CT
• MRI
• Distant:
• Chest XR
• Lung fields CT
• PET is becoming more popular for high grade lesions
low efficacy – good for myxoid tumours, melanoma, lung cancer

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Soft Tissue Tumour

The aims of treatment:

• Resect the tumour

• Preserve function
• Salvage limbs
• Avoid local recurrence
• Avoid complications
• Avoid risk to life - metastasis

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Standard approach:

• High grade:
• Wide surgical excision + radiotherapy
• We usually perform radiotherapy first
• Low grade:
• Wide excision only

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Surgical Aims
• Local Control
• Disease Control
• How:-

Wide surgical margin:

WHAT IS WIDE EXCISION?

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Adductor region

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Anterior compartment

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Please take a history & do an examination.
A growing mass is a tumour.
Do not assume the x-ray report is necessarily correct.
If things change over time then re-consider!
The x-ray report is a help to the clinician – it is not necessarily the answer.
There is no such thing as a growing haematoma.

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 Beware the “growing haematoma”
And the “muscle tear”
Where there has been no injury

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 Bad biopsies
or excisions
• It does not have to be small
• But it should be neat
• No undermining of the skin or tissue
planes

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Pitfalls around the knee

• No X-ray
• Arthroscopy
• If there is an unusual lump -
• Do the arthroscopy first
• Do not biopsy a lump through the arthroscope
• Fleshy lumps are sarcomas
• Be careful of biopsy in the popliteal fossa
• Beware the “growing” haematoma

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Synovial cysts & synovial sarcoma

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Resection without reconstruction

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 Indications for Amputation

Tumour puts life at risk

Tumour puts limb at risk
Risk of local recurrence
Risk of poor function
Risk of delayed healing
Risk of multiple operations - morbidity

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Vital structures
• Lower limb
• Femoral nerve
• Sciatic nerve • Upper limb
• Hip joint • Hand function

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Hypothesis
• Failure to achieve an adequate margin leads to an adverse outcome in
terms of survival

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 Overall survival by width of surgical margins
1.2

Margins
1.0

Margins not defined

.8 Radical
Proportion survived

No residual tumour

Wide 20+ mm
.6
Wide 10-19mm

Wide 5-9mm
.4
Wide 1-4mm

Wide < 1mm

.2
Wide - contaminated

0.0
-20 0 20 40 60 80 100 120 140

5-6 July 2014 OVERALL SURVIVAL - months since first Soft

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 Local recurrence by width of surgical margins

1.1
Proportion local recurrence-free

1.0

Margins
.9
Wide 10 –19 mm

Wide 5 –9 mm
.8
Wide-1-4 mm

Wide << 1mm

.7 Wide - contaminated

.6
-1000 0 1000 2000 3000 4000

Local recurrence - days since first visit

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 Questions

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